Factors associated with tuberculosis treatment outcomes among tuberculosis patients attending tuberculosis treatment centres in 2016-2017 in Mogadishu, Somalia

Introduction World Health Organization (WHO) reported that tuberculosis (TB) was a major health problem and the second leading cause of mortality globally. An estimated 1.8 million TB deaths were reported in 2015. In Somalia, the average TB incidence was 274 cases per 100,000 people in 2014; prevalence was 513 per 100,000 population; and mortality rate excluding human immune deficiency virus (HIV)/TB co-infection was 64/100,000. In addition, the prevalence rates of multi-drug resistant (MDR)-TB are still high, 5.2% among new cases and 40.7% for retreatment cases. The objective of this study was to determine individual and institutional level factors associated with TB treatment outcomes (TB-TOs) among patients attending TBTCs in Mogadishu. Methods The study design was cross-sectional, using quantitative and qualitative methods. Data was collected using interviewer administered semi-structured questionnaires and key in-depth interviews in 2016/2017. Qualitative data was coded using NVIVO8 and quantitative data analyzed using descriptive and inferential statistics at 95% confidence interval using SPSS20 software. Results The study used a sample of 385 TB patients. There were 315(81.8%) successful TB-TOs. Individual level factors-marital status, education level, HIV status, treatment category and knowledge on TB influenced TB-TOs (p-value < 0.05). Being married, educated, HIV-negative, new treatment case and knowledgeable on TB increased odds of successful TB-TOs (OR > 0, p value < 0.05) compared to other patients. TBTCs factors did not influence TB-TOs (p-value > 0.05). Conclusion TB-TOs were mainly affected by patient individual factors. There was need for patient education on TB management and treatment; and improved patient-health provider relationship.


Introduction
TB is an infectious disease that commonly affects the lungs and is caused by bacteria-Mycobacterium tuberculosis [1]. Most infections with the bacteria do not cause TB disease and 90-95% of infections remain asymptomatic [2]. TB can cause infection in persons with impaired immunity [3]. Most infections do not have symptoms, known as latent TB, where in about 10% of these latent infections can develop disease in lifetime which can kill about half of those infected [4]. The symptoms of active pulmonary TB disease are coughing, with sputum or blood, chest pains, fever, weight loss and night sweats [5]. TB is transmitted through droplets from an infected person with active pulmonary disease released in the air through cough, sneeze or talking and then inhaled by another person [6]. TB can also spread through ingesting infected milk or meat (bovine TB) [7]. Medical evaluation of TB includes medical history of exposure, infection and other risk factors like HIV infection; physical examination to assess patient's general health to inform treatment plan; chest x-ray to detect chest abnormalities; and microbiological tests using samples of sputum [8]. Tuberculosis treatment aims to cure TB patients, prevent deaths from TB and to

Knowledge on TB among TB patients attending TBTCs:
Eighty seven percent of TB patients were aware of TB before being diagnosed. The percent of patients informed by family, friends, neighbours or colleagues varied significantly (P < 0.001). A section of 22.9% patients were aware of the cause of TB (P < 0.001) while 54.5% patients were aware of the common signs and symptoms of TB (P = 0.060). Sixty six percent of the patients were aware that TB could be transmitted and prevented (P < 0.001). Proportions of 60.5% and 52% patients were aware of ways in which TB could be transmitted (P < 0.001) and ways in which TB could be prevented (P = 0.007). Ninety four percent of TB patients were aware that TB could be treated and cured (P < 0.001) and 91.9% patients were aware of how TB could be treated and cured (P < 0.001). Generally, a section of 8.1% TB patients had full knowledge on cause; signs and symptoms; possibility and ways of transmission; possibility and ways of prevention; and possibility and ways of treatment/ cure of TB (P < 0.001) ( Table 2).

Attitude of TB patients attending TBTCs: Patients' attitude on
TB was assessed using adherence to dose, perception on seriousness of TB and having talked to someone after diagnosis. A proportion of 285(74%) patients was significantly not positive about TB (P < 0.001). A section of 189(49.1%) TB patients did not talk to anyone about TB after they were diagnosed (P = 0.618). The rest mainly spoke to spouses 59(15.3%), parents 51(13.2%), medical workers 45(11.7%) and close friends 40(10.4%). A section of 90.9% of the TB patients adhered to TB dose (P < 0.001). The TB patients had missed doses for an average of 2.2 times due to depleted drugs; inaccessible TBTCs; and forgetfulness. A proportion of 169(43.9%) patients did not perceive TB is a serious disease unlike 152(39.5%) who perceived it was a serious disease (P = 0.016) ( Table 3).  Table 4). Proportions of 143(37.1%) and 24(6.2%) patients were trained on TB (P < 0.029) and received health educational materials (P < 0.001) on TB from the TBTCs. Health staff service delivery to TB patients had a mean score of 5.43 where 1 was worst and 10 was best (X 2 = 10.503; df = 5; P <0.001) ( Table 4).

Discussion
The study established that most treatment outcomes were successful in Mogadishu. However, this rate of successful treatment outcomes was slightly lower than that of studies conducted in

Competing interests
The authors declare no competing interest.

Authors' contributions
Authors made substantial contributions to conception and design, and/or acquisition of data, and/or analysis and interpretation of data. All the authors have read and agreed to the final manuscript.

Acknowledgments
The authors of this publication, "Factors associated with tuberculosis treatment outcomes among tuberculosis patients attending tuberculosis treatment centers in Mogadishu, Somalia" would like to thank Jomo Kenyatta University of Science and Technology for supervision and Ministry of Health Somalia, Federal Republic of Somalia for ethical approval.